Ankle

Scenario

The following plane film radiograph was taken from a 44YO male presenting after twisting his ankle, when walking down some stairs. It is an isolated injury.

Screenshot-2022-04-27-at-11.57.55

This is an AP and lateral plane film radiograph of an unkown skeletally mature individuals Right ankle. The date and time of the X-Ray is not shown. The most obvious abnormality is that there is a fracture dislocation of the ankle, with the talus shifted laterally. There is a oblique fracture at the level of the syndesmosis through the fibula and an oblique fracture of the medial malleolus. Classification would be a Weber’s B or a Supination External rotation type injury.

I would liaise with my ED collegues/anaesthetists to provide the patient with appropirate analgesia and sedation. A collegue would flex the ipsilateral knee to remove the pull of the gastrocnemius. The deforming forces should then be reversed and a backslab applied. I would maintain reduction in a neutral postion. Following backslab application I would check the N/V status of the foot, repeat X-Rays, document and ensure the limb is elevated.

  • Inproper techqiue
  • Inadequate sedation
  • Soft tissue in joint e.g. periosteum or deltoid ligament

Lauge Hansen classification

Two word descriptor (first word describes the position of the foot at the time of injury e.g. pronation or supination and the second word describes the deforming force e.g. abduction, adduction or external rotation). Fractures are classified into:

  • Supination adduction
  • Supination external rotation
  • Pronation adbuction
  • Pronation external rotation

 

Pott’s Classification – anatomical description of the fracture involving the lateral, medial or posterior malleolus.

 

Weber’s Classification

  • A: Below the syndesmosis
  • B: At the level of the syndesmosis
  • C: Above the syndesmosis
  1. Anterior inferior tibiofibular ligament rupture
  2. Oblique fracture through the lateral malleolus at the level of the syndesmosis (Webber’s B)
  3. Posterior inferior tibiofibular ligament or posterior malleolar fracture
  4. Oblique medial malleolus fracture or deep deltoid ligamentous injury.

 

 

< 60

>60

Weber A (stable)

Walking boot

Walking boot

Weber B (?stable)

Boot/cast and review in 1 week with a weight bearing view

Boot/cast and review in 1 week with a weight bearing view

Weber C (unstable)

Open reduction internal fixation

Closed contact casting if reduction maintained.

ORIF

 

Stress view

Hook test

If removing the screw at 3-4 months then 4 cortices

If leaving the screw in situ then 3 cortices

Joint congruity

Fibula length

Talar shift

A lag screw can be achieved by either technique or design, both require the drill hole to be perpendicular to the fracture line.

  • Lag screw by technique involves overdrilling the near cortex (3.5mm proximal fragment and 2.5 distal fragment).
  • Lag screw by design involves utilising specific screws that don’t engage the near cortex.

Superficial peroneal nerve

Crosses from the lateral compartment of the leg at approximately 10cm proximal to the lateral malleolus.

15 degrees internal rotation of the foot.

AIM trial closed contact casting provides a clinically equivalent outcome to ORIF at a reduced cost to the NHS when used to manage unstable ankle fractures in patients over 60 years old.

fAIM trial is a trial currently being performed, which is comparing closed contact casting and ORIF in patients under 60 years old with an unstable ankle fracture.

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